extracopiesofder(21)t(12;21)plusdeletionofetv6genedueto...

Hindawi Publishing CorporationCase Reports in GeneticsVolume 2012, Article ID 186532, 4 pagesdoi:10.1155/2012/186532

Case Report

Extra Copies of der(21)t(12;21) plus Deletion of ETV6 Gene due todic(12;18) in B-Cell Precursor ALL with Poor Outcome

Marina Araujo Fonzar Hernandes,1, 2 Terezinha de Jesus Marques-Salles,1, 3

Hasmik Mkrtchyan,4 Eliane Maria Soares-Ventura,1 Edinalva Pereira Leite,1

Maria Tereza Cartaxo Muniz,1, 2 Maria Teresa Marquim Nogueira Cornelio,1, 2

Thomas Liehr,4 Neide Santos,3 and Maria Luiza Macedo Silva5

1 Pediatric Oncohematology Center, Hospital Oswaldo Cruz, University of Pernambuco (CEONHPE/HUOC/UPE),50050-210 Recife, PE, Brazil

2 Institute of Biological Science, University of Pernambuco, 50050-210 Recife, PE, Brazil3 Departament of Genetics, Federal University of Pernambuco, 50670-901 Recife, PE, Brazil4 Institute of Human Genetics and Anthropology, 07740 Jena, Germany5 Department of Cytogenetics of the National Center for Bone Marrow Transplant (CEMO-INCA), National Cancer Institute,20230-130 Rio de Janeiro, RJ, Brazil

Correspondence should be addressed to Terezinha de Jesus Marques-Salles, [email protected]

Received 9 December 2011; Accepted 18 January 2012

Academic Editors: C. Lopez Gines, P. Saccucci, and G. Velagaleti

Copyright © 2012 Marina Araujo Fonzar Hernandes et al. This is an open access article distributed under the Creative CommonsAttribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work isproperly cited.

Acute lymphoblastic leukemia (ALL), CD10+ B-cell precursor, represents the most frequent type of childhood ALL from 3 to 6years of age. The t(12;21)(p13;q22) occurs in 25% of cases of B-cell precursor ALL, it is rare in children less than 24 months andhave been related to good prognosis. Some relapse cases and unfavorable prognosis in ALL CD10+ are associated with t(12;21)bearing additional aberrations as extra copies of chromosome 21 and ETV6 gene loss. This report describes the case of a 15 month-year old girl, who displayed a karyotype with addition on chromosome 12p plus trisomy 10 and tetrasomy of chromosome 21.Molecular cytogenetic studies revealed two extra copies of the der(21) t(12;21), trisomy 10 and deletion of the second ETV6 genedue to the dic(12;18). These findings show the great importance of molecular cytogenetic studies to clarify complex karyotypes, todefine prognostic, to carry out risk group stratification and to support correctly disease treatment in childhood acute lymphoblasticleukemia.

1. Introduction

While infant acute lymphoblastic leukaemia (ALL) accountsfor about 3% of leukemias in children below 12 months,it displays specific clinical characteristics with most caseshaving phenotype pro-B, 80% of cases presenting MLL generearrangement, and represents a group of poor prognosis [1].The ALL cases, CD10+ B-cell precursor (BCP), have the inci-dence peak among 3–6-year olds and are considered the mostfrequent (85–90%) type of childhood leukemia with goodprognosis [2]. The characteristic cytogenetic abnormality isthe classic “cryptic” translocation t(12;21)(p13;q22), definedalso as ETV6/RUNX1 (TEL-AML1) gene fusion, detected by

fluorescent in situ hybridization (FISH) in 20–25% of cases[3, 4].

In CD10+ B-cell precursor (BCP) ALL, translocations ordicentrics chromosomes involving 12p are mostly associatedwith loss of 12p material and a lot of partners chromosomesare described. Cases with these abnormalities are rarelydescribed in children younger than 24 months [5]. Chro-mosome 12 breakpoint is most often localized in 12p13,involving ETV6 gene, with fusion of 5′ end of ETV6 with3′ end of the partner and sometimes accompanied with aconcomitant deletion of other ETV6 allele gene [5]. In B-cellprecursor (BCP) ALL some reports have shown that patientswith t(12;21) and secondary abnormalities such as complex

2 Case Reports in Genetics

18der(12)t(12;21) dic(12;18)

cep 12 cep 18

MCB12

der(12) der(12) der(21) der(21)

RUNX1

ETV6

t(12;21) t(12;18)

1 2 3 4 5

6 7 8 9 10 11 12

13 14 15 16 17 18

19 20 22 X Y21

1 2 3 4 5

6 7 8 9 10 11 12

13 14 15 16 17 18

19 20 22 X Y21

(a) (b)

(c)

(d)

(e)

Figure 1: Conventional and molecular cytogenetics dates. (a) G-banding. The arrows show add (12p), −18, and +21, +21; (b) FISH showstwo copies of der(21)t(12;21) (arrows), two 21 chromosomes, and ETV6 deletion; (c) M-FISH showing the 10 trisomy and der(12)t(12;21);dic(12;18)(p12;q11.21), der(21)t(12;21), +21; (d) CEP probe 12 and 18 shows dic(12;18); (e) MCB: showing the breakpoints of theder(12)t(12;21) and der(12)t(12;18).

karyotypes, extra copy of der(21)t(12;21), gain of one or twoRUNX1 allele, or deletion of second ETV6 allele gene have apoor prognosis [5, 6].

Here a case of a 15-month-year old girl is reported inwhich conventional cytogenetic analysis revealed addition onchromosome 12p plus trisomy 10 and tetrasomy of chromo-some 21. Molecular cytogenetic studies have revealed trisomy10 plus two extra copies of the der(21)t(12;21) and deletionof the second ETV6 gene due to the dic(12;18). The infantdid not respond to chemotherapy and consequently died dueto disease progression.

2. Materials and Methods

2.1. Case Report. The 15-month old girl admitted at thePediatric Oncohematology Center, University HospitalOswaldo Cruz (Recife, Pernambuco) with history ofanaemia and bone pain. The child showed pallor, petechiae,

microadenopathy, and hepatomegaly. The blood peripheralexamination revealed the following: Hg = 9,8 g/dL; WCB =22.629/mm3 (91% lymphoblast), platelets count = 21.000/mm3. The bone marrow was hypercellular with 90% infil-tration by blast ALL-L1. Immunophenotyping studies show-ed the following: CD45+; TdT+; HLA-Dr+; CD22+, CD19+;CD10+. RT-PCR analysis demonstrated the presence ofETV6/RUNX1 transcripts. The child was treated with high-risk GBTLI-99 ALL protocol and relapsed after 17 monthsfrom diagnosis. At relapse she was treated with BFM-90 ALLprotocol, but died due to progressive disease.

2.2. Conventional Cytogenetic and Molecular Analysis. Con-ventional cytogenetic analysis was performed on unstimu-lated bone marrow cells cultivated for 24 hours. G-bandingwas done according to standard protocol. Karyotype wasdescribed according to ISCN (2009) [7]. FISH analysis withLSI MLL dual colour, break-apart rearrangement probe

Case Reports in Genetics 3

(Vysis UK), and LSI TEL/AML1 ES dual colour, extra signaltranslocation probe (Vysis UK) were used according to themanufacturer’s instructions. At least 100 interphase nucleiwere analyzed in each study. Multicolor FISH (M-FISH)using 24 whole chromosome painting probes, FISH withCEP12 and CEP18 were applied and multicolor banding(MCB) was performed as previously described [8, 9].

3. Results

Cytogenetic study by G-banding revealed a complex kary-otype 48, XX, +10, add(12p), −18, +21, +21[7]/46, XX[13](Figure 1(a)). FISH showed no rearrangements to MLL gene,and with dual colour probe LSI TEL/AML1 ES identifiedthe ETV6/RUNX1 fusion with extra copy of der(21)t(12;21),extra chromosome 21, and deletion of second ETV6 genein 50% of interphase nuclei (Figure 1(b)). To better char-acterize the karyotype M-FISH (Figure 1(c)) and MCB forchromosomes 12 and 18 were performed. MCB showeda translocation involving the regions 12p12 and 18p11.21and FISH with CEP probes confirmed unmasked dic(12;18)(Figures 1(d)–1(e)). The final karyotype was characterizedas 48, XX, +10, t(12;21)(p13,q22), dic(12;18)(p12;q11.21),−18, +der(21)t(12;21), +21[10]/46, XX[10].

4. Discussion

Several studies have investigated the prognosis value oft(12;21) positive ALL, but in general it is associated with agood prognosis. However, a few cases present relapsed (10–20%) [10]. The heterogeneity of clinical response seems todepend on the intensity of treatment and additional geneticchanges [11].

The case related here, a BCP-ALL with t(12;21) thatpresented extra copy of der(21)t(12;21) and a deletion ofthe second ETV6 gene due to the dic(12;18) plus extra copy,had a progressive disease despite the aggressive treatment. Allthose aberrations when found are rare and described in only1% of t(12;21) positive ALL [11]. The favourable prognosisof translocation t(12;21) seems to be impaired by the pres-ence of extra aberrations [12–14]. The extra copy der(21) hasbeen reported to be more frequently in relapsed case and thepresence at diagnosis is linked to an unfavourable prognosis[15]. Whether other abnormalities, such as deletion of ETV6and extra copy of RUNX1 also, contribute to unfavourableprognosis is still controversial [16, 17]. However, the ETV6gene deletion in childhood ALL is discussed as a hint on atumour suppressor gene function [18].

The case described here showed the great importance ofmolecular cytogenetic studies to clarify the cryptic transloca-tions and marker chromosomes, mainly to define prognostic,risk group stratification and to provide appropriate supportin treating the acute lymphoblastic leukemia. Other casesare needed in order to define whether those aberrationsshould be treated only with chemotherapy or, as in someMLL rearrangements cases, the bone marrow transplantationshould be part of the first remission treatment.

Acknowledgments

This work was partially supported by CAPES (Project no.301/08) and German Academic Exchange Service (DAAD)(no. D/07/09624) and the Monika Kutzner Stiftung (Ger-many). The authors are also grateful to “Programa Crianca eVida” for the helpful support in the childhood cancer net-work care.

References

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[2] R. Pieters, M. Schrappe, P. De Lorenzo et al., “A treatment pro-tocol for infants younger than 1 year with acute lymphoblasticleukaemia (Interfant-99): an observational study and a mul-ticentre randomised trial,” The Lancet, vol. 370, no. 9583, pp.240–250, 2007.

[3] S. P. Romana, M. Le Coniat, and R. Berger, “t(12;21): anew recurrent translocation in acute lymphoblastic leukemia,”Genes Chromosomes and Cancer, vol. 9, no. 3, pp. 186–191,1994.

[4] P. R. G. Zen, M. E. Z. Capra, L. M. R. Silla et al., “ETV6/RUNX1 fusion lacking prognostic effect in pediatric patientswith acute lymphoblastic leukemia,” Cancer Genetics and Cyto-genetics, vol. 188, no. 2, pp. 112–117, 2009.

[5] A. Peter, T. Heiden, T. Taube, G. Korner, and K. Seeger,“Interphase FISH on TEL/AML1 positive acute lymphoblasticleukemia relapses—analysis of clinical relevance of additionalTEL and AML1 copy number changes,” European Journal ofHaematology, vol. 83, no. 5, pp. 420–432, 2009.

[6] A. Attarbaschi, G. Mann, M. Konig et al., “Incidence and rele-vance of secondary chromosome abnormalities in childhoodTEL/AML1+ acute lymphoblastic leukemia: an interphaseFISH analysis,” Leukemia, vol. 18, no. 10, pp. 1611–1616, 2004.

[7] L. G. Shaffer, M. L. Slovak, and L. J. Campbell, Eds., ISCN2009: An International System for Human Cytogenetic Nomen-clature, S. Karger AG, Basel, Switzerland, 2009.

[8] T. Liehr, H. Starke, A. Weise, H. Lehrer, and U. Claussen,“Multicolor FISH probe sets and their applications,” Histologyand Histopathology, vol. 19, no. 1, pp. 229–237, 2004.

[9] A. Weise, K. Mrasek, I. Fickelscher et al., “Molecular definitionof high-resolution multicolor banding probes: first within thehuman DNA sequence anchored FISH banding probe set,”Journal of Histochemistry and Cytochemistry, vol. 56, no. 5, pp.487–493, 2008.

[10] H. Kempski, J. Chalker, J. Chessells et al., “An investigation ofthe t(12;21) rearrangement in children with B- precursor acutelymphoblastic leukaemia using cytogenetic and molecularmethods,” British Journal of Haematology, vol. 105, no. 3, pp.684–689, 1999.

[11] W. A. G. Stams, H. B. Beverloo, M. L. den Boer et al., “Inci-dence of additional genetic changes in the TEL and AML1genes in DCOG and COALL-treated t(12;21)-positive pedi-atric ALL, and their relation with drug sensitivity and clinicaloutcome,” Leukemia, vol. 20, no. 3, pp. 410–416, 2006.

[12] C. D. Chow, L. Dalla-Pozza, D. J. Gottlieb, and M. S. Hertz-berg, “Two cases of very late relapsing childhood ALL carryingthe TEL:AML1 fusion gene,” Leukemia, vol. 13, no. 11, pp.1893–1894, 1999.

[13] R. M. Slater, E. V. Drunen, B. Roitzheim, S. Viehmann, H. B.Beverloo, and J. Harbott, “Variation in ETV6 and AML1 in

4 Case Reports in Genetics

t(12;21) childhood ALL revealed by interphase FISH,” Blood,vol. 90, pp. 222–223, 1997.

[14] M. Marineau, G. R. Jalali, K. E. Barber et al., “ETV6/RUNX1fusion at diagnosis and relapse: some prognosis indicationsgenes,” Chromosomes Cancer, vol. 43, pp. 54–71, 2005.

[15] I. F. Loncarevic, B. Roitzheim, J. Ritterbach et al., “Trisomy21 is a recurrent secondary aberration in childhood acutelymphoblastic leukemia with TEL/AML1 gene fusion,” GenesChromosomes and Cancer, vol. 24, no. 3, pp. 272–277, 1999.

[16] M. L. Loh and J. E. Rubnitz, “TEL/AML1-positive pedi-atric leukemia: prognostic significance and therapeutic ap-proaches,” Current Opinion in Hematology, vol. 9, no. 4, pp.345–352, 2002.

[17] R. Stanchescu, D. R. Betts, G. Rechavi, N. Amariglio, andL. Trakhtenbrot, “Involvement of der(12)t(12;21)(p13;q22)and as well as additional rearrangements of chromosome12 homolog in ETV6/RUNX1-positive acute lymphoblasticleukemia,” Cancer Genetics and Cytogenetics, vol. 190, no. 1,pp. 26–32, 2009.

[18] C. H. Pui, M. V. Relling, and J. R. Downing, “Mechanismsof disease: acute lymphoblastic leukemia,” The New EnglandJournal of Medicine, vol. 350, no. 15, pp. 1535–1548, 2004.

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